A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Measure the client's vital signs before the client walks.

Determine if the client needs to have a gait belt applied.

Report the onset of any dizziness or lightheadedness.

Instruct the client about signs of orthostatic hypotension.

Offer to assist the client to void prior to walking in the hall.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

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Correct Answer is C

Explanation

Choice A reason: Listing the procedural steps is helpful but does not demonstrate practical competence.

Choice B reason: Reviewing glycosylated hemoglobin levels provides information about long-term glucose control but does not directly assess the technique.

Choice C reason: Observing the adolescent as he demonstrates the self-injection technique ensures that he has understood and can correctly perform the procedure, providing the best evaluation of teaching effectiveness.

Choice D reason: Describing the level of comfort provides insight into his confidence but not necessarily his technical competence.

A. Research the religion on different social media platforms. B. Consult with a nurse who shares the same religious beliefs. C. Explain that every client will receive the same high level of care. D. Ask the client about individual care preferences.

Correct Answer is D

Explanation

Choice A reason: Researching the religion on social media is not a reliable or appropriate method for understanding individual care needs.

Choice B reason: Consulting with a nurse who shares the same religious beliefs may provide insight but does not address the specific concerns of the client.

Choice C reason: Explaining that every client receives the same high level of care does not address the client's individual religious needs and concerns.

Choice D reason: Asking the client about individual care preferences ensures that the nurse understands and respects the client's specific religious beliefs and practices.

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A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Correct Answer is C

Explanation

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

Correct Answer is D

Explanation

The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

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